Inpatient Psychiatric Facility Quality Reporting Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10432 Reconsideration Request	Form and Instruction	Modified	Available
Form CMS-10432 Decline to Participate	Form and Instruction	Modified	Available
Form CMS-10432 Data Accuracy and Completeness	Form and Instruction	Modified	Available
Form CMS-10432 Notice of Participation	Form and Instruction	Modified	Available
Form CMS-10432 Data Collection	Form and Instruction	Modified	Available
Form CMS-10432 Withdrawal	Form and Instruction	Modified	Available
IPFQR_Notification Letter_Aug_26_2012.docx	Supplementary Document	Uploaded 2012-09-05	Available
CMS 10432 Supporting Statement A.docx	Supporting Statement A	Uploaded 2012-09-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Reconsideration Request
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Decline to Participate
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Data Accuracy and Completeness
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Notice of Participation
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Data Collection
202349	Inpatient Psychiatric Facility Quality Reporting Program	Form and Instruction	Modified	Withdrawal

ICR Details

OMB Control No: 0938-1171	ICR Reference No: 201209-0938-003
Status: Historical Active	Previous ICR Reference No: 201205-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Inpatient Psychiatric Facility Quality Reporting Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/20/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/14/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2015	36 Months From Approved
Responses	471,811	0	0
Time Burden (Hours)	1,415,433	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 10322 of the Affordable Care Act authorizes the establishment of a new quality reporting program for Inpatient Psychiatric Facilities (IPFs). Beginning in FY 2014 and subsequent fiscal years, the quality measures IPFs are required to collect and submit six (6) quality measures to CMS. IPFs failing to submit the quality measures will receive a 2% reduction. In an effort to minimize burden and maximize efficiency, CMS has leverage existing system within CMS to collect aggregated and calculated measure rates from the IPFs, in a form, manner and time as specified by CMS, via a secure portal known as the QualityNet Web site beginning of October 1, 2012 for FY2014 payment determination year. CMS is proposing to implement some procedural requirements to align with current quality reporting programs. These procedural requirements would involve submitting necessary forms to comply with the IPFQR Program and aligns with current CMS reporting requirements for other quality programs. The aforementioned forms are the Notice of Participation From, Decline to Participate Form, Participation Withdrawal Form, Reconsideration Request Form, Disaster Waiver form and the IPFQR notification form letter.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 10322 Name of Law: Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 10322 Name of Law: Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AR12	Final or interim final rulemaking	77 FR 53258	08/31/2012

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Inpatient Psychiatric Facility Quality Reporting Program	CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432, CMS-10432	Data Collection ,   Notice of Participation ,   Data Accuracy and Completeness ,   Decline to Participate ,   Withdrawal ,   Reconsideration Request

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	471,811	0	471,811	0	0	0
Annual Time Burden (Hours)	1,415,433	0	1,415,433	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Between the draft rule and the final rule, there have been minor editorial changes to the forms. The burden has not changed.

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Annual Cost to Federal Government: $41,600

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/14/2012

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